Your information is 100% safe.
Who can we thank for referring you?
Home Phone *
Cell Phone *
Work Phone Mother *
Work phone Father *
Email Address *
Type Of Birth
Problems during pregnancy
Problems during labor/delivery
# hours of sleep per night
Date of last visit
Purpose for Visit
Present Health History (please list any health issues, present & past)
Purpose for Today's Appointment
When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both the patient and doctor to be working towards the same objective. Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment.
Adjustment: An adjustment is the specific application of forces to facilitate the body's correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine.
Health: A state of optimal physical, mental and social well-being not merely the absence of infirmity.
Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column, which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body's innate ability to express its maximum health potential.
We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area.
Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body's innate wisdom. Our only method is specific adjusting to correct vertebral subluxations.
I, have read and fully understand the above statements. All questions regarding
the doctor's objectives pertaining to my care in this office have been answered to my complete satisfaction.
All questions regarding the doctor's objectives pertaining to my care in this office have been answered to my complete satisfaction.
I therefore accept chiropractic care on this basis.
Consent to evaluate end adjust a minor child
I being the parent or legal guardian of my child have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive chiropractic care.
This is to certify that to the best of my knowledge I am not pregnant, and the above doctors and their associates have my permission to perform an x-ray evaluation. I have been advised that x-ray can be hazardous to an unborn child.
Date of last menstrual period